Provider Demographics
NPI:1952418089
Name:JACKSON, STEPHEN H (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:H
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4787 ALBEN BARKLEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002
Mailing Address - Country:UM
Mailing Address - Phone:270-442-9461
Mailing Address - Fax:270-441-0079
Practice Address - Street 1:510 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-6334
Practice Address - Country:US
Practice Address - Phone:618-997-6800
Practice Address - Fax:618-998-9635
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24187207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64241870Medicaid
1163202Medicare ID - Type Unspecified
KY64241870Medicaid